The Strange, Contagious History of Bulimia

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In 1972, a woman checked into London’s Royal Free Hospital to be treated for anorexia. “I found her symptoms to be unique,” Gerald Russell, the British psychologist who treated her, tells me. “They didn’t match the diagnostic criteria for anorexia at all.” Unlike his emaciated patients with sallow skin and big eyes, Russell’s new patient was of average weight. Her face was full. Her cheeks were pink as the skin of an onion. She was the first of roughly thirty instances of this unusual condition that crossed the threshold of his clinic over the next seven years, each person presenting with perplexing purging behaviors secondary to binge eating. Russell wasn’t dealing with anorexia nervosa, he realized, but something as yet undefined by psychology or medicine.

In fact, he had stumbled upon a condition that science had yet to see in large numbers or identify at any time in the long history of eating disorders. Psychological Medicine published Russell’s ensuing paper on these unusual cases; in it, he described the key features of this novel mental illness he was now referring to as bulimia nervosa. Many in the scientific community objected to Russell’s conclusions, pointing to the limited and problematic sample size he’d used. At the time, however, there were simply too few cases for Russell to draw from. The pool in the 1970s was just too small.

As bulimia gained further diagnostic legitimacy in 1980 with its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, Russell ruefully tracked its unexpectedly swift spread across Europe and North America, where it infiltrated college campuses, affecting 15 percent of female students in sororities, all-women dormitories, and female collegiate sports teams. The disease moved through the halls of American high schools, where binging, fasting, diet pill use, and other eating disorder symptoms easily clustered. He chased its dispersion across Egypt, where the number of new cases grew to 400,000. In Canada, it swelled to 600,000. In Russia, 800,000. In India, 6 million. In China, 7 million. In the UK, one out of every one hundred women was now developing the disorder.

“It makes you wonder if maybe bulimia wasn’t a new eating disorder, that it was always there and people just didn’t notice it or talk about it before your paper came out,” I offer.

Russell demurs politely. If the hidden afflicted numbered as overwhelmingly high as they now seem, surely the condition would have made itself known well before he — or anyone, for that matter — identified it. “You might suggest it required somebody to come along and put two and two together before people felt safe talking about bulimia, but I don’t believe that.

“Until then,” he continued, “the disorder was extremely rare. But after 1980, it became widespread in a very short period of time. Once it was described, and I take full responsibility for that with my paper, there was a common language for it. And knowledge spreads very quickly.”

With this knowledge, Russell’s discovery took on characteristics of a pandemic that was set to claim 30 million people, but neither he nor anyone could do a thing at that point to stop it. He was confronted, he says, by a problem of entropy, a gradual decline into disorder with devastating implications for social contagions: once they are out, they are virtually impossible to rein it back in again.

Even so, a single academic journal article and a mention in a dense diagnostic manual read mostly by psychology professionals doesn’t quite explain how bulimia leapt from a few isolated cases to infect people across the globe. Russell agrees: we are missing a critical connection between academia and everyone else.

Following the debut of bulimia nervosa in the DSM-III, the University of Chicago put out a press release publicizing its own rather novel data on a kind of sequela of anorexia. Mademoiselle and Better Homes and Gardens, among other popular women’s magazines, took the press release and described the effects of a new “binge-purge syndrome” making inroads into American culture. With Russell’s data proliferating among diagnosticians, and the term itself entering the lexicon through trendy magazines with wide distributions, cases of bulimia rose steeply. Once people realized they were able to eat whatever they wanted and as much as they wanted without a weight consequence, binging and purging became the new strategy for weight management. It was no coincidence that these unhealthy and harmful behaviors took hold at the same time that obesity — which the researchers Nicholas Christakis and James Fowler have found to be as contagious as any eating disorder — doubled in the US.

Of course it’s not about media. It’s about awareness.

The theory of media’s culpability in the spread of social contagions is not a new one. Psychologists studying the developmental psychopathology of eating disorders have led dozens of controlled experiments finding a near-perfect link between mass media and eating disorder symptoms. The question in my mind now isn’t whether media have a part to play in replicating social contagions; if we were able to purge ourselves of certain conduits of influence like media itself, we might have an easier time stopping transmission. Rather, I question just how big a part media actually play in spreading them.

To answer that, Russell refers to an exceptional case that transpired in the Republic of Fiji. By the mid-1990s, he says, bulimia was rampant across industrialized parts of the world, but not so much in developing countries. The Harvard Medical School associate professor Anne E. Becker figured that cultural context likely accounted for this barrier to transmission. To test her theory, she sought out a place completely isolated from Western influence. In all of Fiji’s history, the republic had yet to report a single case of someone suffering from an eating disorder. That all changed in 1995.

“What happened in 1995?” I ask Russell.

Melrose Place, he says. Xena: Warrior Princess. Beverly Hills, 90210. “That was the year the first television arrived to the island republic.”

After just three years of exposure to American television shows, 11 percent of Fiji’s adolescent girls admitted to Becker that they had purged their food at least once to lose weight. In that time, the risk of developing an eating disorder jumped from 13 percent to 29 percent. More than 80 percent revealed that television influenced them or their friends to be more conscious about body shape or weight. By 2007, 45 percent of girls from the main island reported purging their food.

Becker also found that the effect of media exposure went beyond eating disorders. She recorded an increase in personal ambition based on certain characters that viewers watched on television. In one of her studies, 80 percent of the girls said they planned to eschew traditional agrarian jobs for professional careers, specifically those that only wanted thin women. The republic also experienced a rise in the social contagion of emotional strain among teenage girls. Fiji’s society was changing quickly, and psychological problems accompanied these massive cultural shifts as media transmissions carried along even more social contagions.

All of this seems like an awful lot of blame to heft onto mass communication, I comment. Is the answer to understanding and stopping the spread of social contagions really as simple as curbing media and their messages? “As that very elegant Fiji study by my American colleague found, media matters. But the truth often requires us to dig a bit further,” Russell replies, then remarks, with a bit of cunning, “Of course it’s not about media. It’s about awareness.”

***

The writer Johann Wolfgang von Goethe writes that in nature we never see anything isolated, but everything in connection with something else. It is a growing awareness of these connections that has me thinking quite a bit about the stark picture that Russell painted of social contagion events, illustrating the way a little exposure can lead to large effects like a global pandemic of bulimia.

I’m finding it difficult to comprehend the full deleterious influence of awareness. Russell has explained that we acquire eating habits by watching characters on television, by noticing the way our friends eat or the images they post online, and by unconsciously registering subtle cues in the culture itself. I can accept that exposure creates opportunity for the spread of social contagions, but how then does one defend against awareness? You can’t go through life closing your eyes and shutting your ears.

Following my chat with Russell, I seek out a copy of a dissertation written in the early eighties that includes one of the first-ever references to a condition resembling bulimia, as well as an effective treatment for it. The author is the psychologist Deborah Brenner-Liss. She used to work at an eating disorder clinic in New York and is now running a small private practice in San Francisco. Brenner-Liss’ office is big and bright and staged like the studio set of a television show about a psychologist, with a plush sofa and big armchairs deliberately staged to provoke a conversation, a divulging, a confession. She is lean with a small chin, pronounced cheeks, and slender shoulders. The lines in the skin of her face run deep.

She recounts a now-familiar story of bulimia’s genesis and its spread, along with her own exploration of the early literature on binging and purging. Like Russell and Becker, Brenner-Liss found that once the condition started appearing in the media, the condition spread unrestrained.

“Our intentions as researchers and practitioners fighting bulimia were good,” she emphasizes. “We wanted to get the word out about it to help professionals understand that this exists, and to rally to find effective ways to treat it.” That was the task, to find a way to halt the spread.

As Brenner-Liss describes desperate measures to find a treatment for bulimia, she relates some harrowing facts. For instance, today 60 percent of people that receive treatment for eating disorders recover, sustaining a healthy weight and normal diet, she tells me. Another 20 percent make partial recoveries. Brenner-Liss is among them; as Russell was writing about an ominous variant of anorexia, and the University of Chicago was putting out press releases, she was one of the first Americans to both develop the symptoms of bulimia and receive treatment for them.

Here in the tech center of San Francisco, we call the people who first try new technology early adopters, I say. “That’s what I am then,” she says. She speaks with me about her earliest experiences with compulsive overeating and purging, as well as finally encountering a successful treatment. Her personal story tracks remarkably well with the cultural fulcrum toward perfect models, the Playboy centerfolds, beauty pageant contestants, and television actresses, as well as the rise of diet products in the seventies and eighties that perpetuated the desire and means to achieve these looks. Not only did the media come to glorify a slender ideal, they also emphasized its importance, and the importance of appearances in general that went into shaping identity, gender roles, values, and beliefs. To treat this perfect storm of catchable body image standards, openness to restrictive eating behaviors, and feelings of despair, pugilists of this pandemic would, in due course, introduce prosocial media campaigns to reinforce healthy body weight, antidepressants, and evidence-based psychotherapies.

In the early days, however, with very few options for treatment available to her, Brenner-Liss sought out support groups, meetings of eight or ten people who exhibited similarly unique eating behaviors as her own. Some members of these groups exercised excessively. Others dosed their bodies with laxatives. Many presented with chipped teeth, eroded stomach linings, brittle hair. Despite their symptoms, what connected them all was a purposeful act of engaging in that most delicate of equations, seeking the balance between consumption and depletion, impulse and restraint.

“Whatever it was we were doing in those living rooms, I suddenly found I was starting to get better,” she reveals. The curious curative nature of these support groups went well beyond talking, relating personal experiences, and offering empathetic understanding. There was something about being in the presence of others who were trying to eat healthfully and also engaging in nourishing activities that began influencing healthy behaviors in her. These tightly knit, highly influential social networks fostered her motivation for positive behavior changes and stoked the stamina in her to stay in the fight.

In other words, she says, members of her support group, by virtue of simply attending the meetings, were catching healthier eating behaviors from each other, along with motivation, resilience, and hope by way of observation and unconscious mirroring. Though they didn’t know it at the time, members of Brenner-Liss’ support group were combatting the social contagions contributing to bulimia with other social contagions.

Support groups would go onto gain popularity in the eighties in greater numbers than ever before as researchers at the University of Illinois found empirical evidence reinforcing what might be considered their contagious benefits. As a practicing psychologist today, Brenner-Liss has incorporated group therapy and peer support networks into treatment for her own patients with eating disorders to great success. “What I’ve been able to do with our groups is to subtly invite healthy competition toward recovery,” she tells me. Social contagions work in their favor.

***

To a layperson, this sounds a lot like exchanging one idea for another —simple enough. Yet all of this creates a very different portrait about the connection between exposure, knowledge, and cures than the one Russell presented me. I explain Russell’s theory of awareness to Brenner-Liss, how he believes that even unconscious exposure to an idea and a behavior spreads them. No matter how recovery-focused one keeps support groups, sometimes an unhealthy competition erupts, he’d said. For every person that support groups cure, others leave group therapy having developed worse symptoms than those they had when they entered it. Bulimia is so contagious that support groups and in-treatment facilities designed to help patients are also primary spreading agents.

Further inquiry only seems to justify Russell’s troubling conclusion. In 2004, the British National Center for Eating Disorders reported that inpatient treatment and specialist units serve to create opportunities for exposure to the worst cases, allowing participants to catch more severe eating disorder symptoms, dangerous behavioral modeling, and harmful attitudes towards treatment that perpetuate well beyond the formal group therapy. Peeling back the processes even farther, the psychiatrist Walter Vandereycken examined ethnographic reports and qualitative investigations to find that sitting within close range of others exposes people to the worst cases and leads patients to unintentionally contend for the worst symptoms. Treatment, he reported, can do more damage than good by allowing the harsher and crueler strain to jump to new hosts.

Where Russell finds a threat in exposure, Brenner-Liss finds healing and a road to the remission of symptoms. Are media and group exposure vectors for spread, I continue to wonder, or are they vectors for treatment?

“Maybe it’s a little of both,” she offers. The same processes of mirroring and unconscious competition that allow people to encode dangerous thoughts, behaviors, and feelings from others might just be the very same that spread beneficial social contagions.

“Then what tips the scale?”

“Personal susceptibility. Environment. The unknown.” She shrugs her shoulders.

***

Riding the train home later that afternoon, I mull over the mechanisms that allow unique people to share universal expressions and similar empathetic responses to one another. Automatic attunement guides us to unintentional mirroring of thoughts, behaviors, and feelings, phenomana that share a language perceptible on a level of the invisible, unknowable unconscious. I consider the findings of Brenner-Liss, who like others, trusts that awareness is a vessel for treatment and cure. Yet, as Russell and Baker discovered, awareness will exacerbate a social contagion event, the same way that spreading knowledge about bulimia helped to triple the frequency of new cases in 10-to-39-year-old women between the late eighties and early nineties. The rate dipped a bit as treatment caught up with the illness, but the number rose steeply again in 1992, shortly after Princess Diana publicly disclosed her battle with bulimia. Her revelation brought tremendous awareness to the condition. It corresponded both with an uptick in people seeking treatment for the first time, as well as an explosion of new cases as the strange contagion spread farther than ever.

There’s no easy answer here, unfortunately. Stopping a social contagion sometimes means using tools of remission and transmission, exploiting a cure that also spreads the disease. Ultimately, it’s a numbers game: save some, lose others, and hope against hope that in the end we come out ahead.